DESCRIPTION

The Clinical Documentation Specialist role involves the evaluation of physician documentation, utilizing clinical expertise to ensure that the patient's severity of illness and risk of mortality are accurately portrayed in the medical record for specificity and increased coding accuracy. Interacts with physicians, clinical staff, and health information management professionals. Works with coding staff to ensure that documentation of discharge diagnoses and any co-existing co-morbidities are a complete reflection of the patient's clinical status and care.

Key Responsibilities:

• Performs complex reviews of patient's medical documentation, evaluating quality measures, consistency, completeness of documents, and accuracy for severity of illness (SOI) and risk of mortality (ROM).
• Establishes productive working relationships in regular communications with clinicians, patient care staff, and health information management (HIM), and coding personnel, working on complex cases to identify documentation gaps, clarify questions, and ensure appropriateness of DRG (diagnosis-related groups) assignment.
• Collaborates with HIM coding staff to ensure that all clinical documentation at discharge is compliant and accurately reflects the patient's condition, treatments, and any co-morbidities.
• Participates in medical record reviews on specific cases involving mortalities, complications, and other situations requiring secondary reviews.
• Analyzes complex clinical case data to identify trends, errors, inconsistencies, variances, or red flags that may delay or hinder third-party reimbursement.
• Recommends timely and effective strategies for revising or correcting clinical documentation to resolve problems and improve compliance.
• Monitors changes and updates in regulatory requirements for clinical documentation.
• Reviews and analyzes inpatient records for appropriateness and compliance with all federal, state, and other regulatory requirements.
• Maintains current knowledge of ICD-10 coding guidelines, DRG systems, and reimbursement issues.
• Serves as an educational resource to all levels of clinical staff and contributes to the development of curriculum for in service trainings and education of professional staff to achieve improved results in clinical documentation and appropriate reimbursement.
• Other duties as assigned.

MINIMUM QUALIFICATIONS

• Bachelor's degree in nursing (BSN) or related area, and/or equivalent combination of experience/training.

• Three (3) or more years of experience with the clinical and operational issues involved with inpatient care, including the diagnoses, treatments, medical procedures, complications, co-morbidities, discharge, and other practices that are part of effective clinical care systems.

• Professional work experience as Clinical Documentation Specialist.

• Adult ICU or Telemetry work experience.

• Interpersonal skills and ability to work with all levels of physicians, advanced practice providers and staff onsite and face-to-face.

PREFERRED QUALIFICATIONS

• MSN or other Master's degree.

• Certified Clinical Documentation Specialist (CCDS/CDIP).

SPECIAL CONDITIONS

• Must be able to work various hours and locations based on business needs.

• Must be able to work onsite throughout UC San Diego Health's facilities full time Mon-Fri, duties as assigned.

• This position is located primarily in La Jolla, but may need to work in Hillcrest based on business needs.

• Employment is subject to a criminal background check and pre-employment physical.